Dynamic use of fibrinogen under viscoelastic assessment results in reduced need for plasma and diminished overall transfusion requirements in severe trauma.

BACKGROUND: Despite advances in trauma management, half of trauma deaths occur secondary to bleeding. Currently, hemostatic resuscitation strategies consist of empirical transfusion of blood products in a predefined fixed ratio (1:1:1) to both treat hemorrhagic shock and correct trauma-induced coagulopathy. At our hospital, the implementation of a resuscitation protocol guided by viscoelastic hemostatic assays (VHAs) with rotational thromboelastometry has resulted in a goal-directed approach. The objective of the study is twofold, first to analyze changes in transfusion practices overtime and second to identify the impact of these changes on coagulation parameters and clinical outcomes. We hypothesized that progressive VHA implementation results in a higher administration of fibrinogen concentrate (FC) and lower use of blood products transfusion, especially plasma. METHODS: A total of 135 severe trauma patients (January 2008 to July 2019), all requiring and initial assessment for high risk of trauma-induced coagulopathy based on high-energy injury mechanism, severity of bleeding and hemodynamic instability were included. After 2011 when we first modified the transfusion protocol, a progressive change in transfusional management occurred over time. Three treatment groups were established, reflecting different stages in the evolution of our strategy: plasma (P, n = 28), plasma and FC (PF, n = 64) and only FC (F, n = 42). RESULTS: There were no significant differences in baseline characteristics among groups. Progressive implementation of rotational thromboelastometry resulted in increased use of FC over time ( p < 0.001). Regression analysis showed that group F had a significant reduction in transfusion of packed red blood cells ( p = 0.005), plasma ( p < 0.001), and platelets ( p = 0.011). Regarding outcomes, F patients had less pneumonia ( p = 0.019) and multiorgan failure ( p < 0.001), without significant differences for other outcomes. Likewise, overall mortality was not significantly different. However, further analysis comparing specific mortality due only to massive hemorrhage in the F group versus all patients receiving plasma, it was significantly lower ( p = 0.037). CONCLUSION: Implementing a VHA-based algorithm resulted in a plasma-free strategy with higher use of FC and a significant reduction of packed red blood cells transfused. In addition, we observed an improvement in outcomes without an increase in thrombotic complications. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Cohort Study on the Implementation of a Surgical Checklist from the Operating Room to the Postanesthesia Care Unit.

PURPOSE: To provide evidence of a well-structured information transfer that prevents the loss of information relevant to patient care. DESIGN: Pre-post cohort study on the implementation of a surgical checklist from the operating room to postanesthesia care unit. METHODS: Main variable was the transfer of relevant and correct information. The secondary variables include time, interruptions, and satisfaction. FINDINGS: In the prechecklist stage, 59 transfers were collected; with an average time of 68.5 seconds, 41.7% of the transfers encountered interruptions, and only 8.5% of the reports were complete with all data. After instituting the checklist, 63 transfers were analyzed with an average time of 96.4 seconds, no interruptions occurred in 71.3% of the transfers, and all the items were transmitted in 92.1% of the cases. Number of interferences decreased. Transfer time increased significantly, but 80.3% of staff found the checklist useful. CONCLUSIONS: A written and structured checklist minimizes the loss of relevant information, thus improving safety in the process.